Occupational,
Physical, and Speech Therapy
Retrospective Review and Billing 101
Presented by
Kay Ewalt and Karen Young
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© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Retrospective Therapy Review
Medicaid Retrospective Therapy Review
 Medicaid is contracted with Qsource of Arkansas to
perform post-payment audits for Occupational, Physical,
and Speech-Language therapy services on children under
the age of 21.
 Audits are selected randomly each quarter.
 A child is only eligible for selection every 12 months.
 Audit selection is based on claims billed and paid in the
previous quarter.
Submitting Requested Charts for Review
The following information is included with each quarter’s chart requests:
 Therapy Chart Request Reference Sheets (purple sheets).
 Master List – Check to ensure you have received all the Therapy
Request Cover Sheets listed.
 Frequently Asked Questions Reference Sheets.
 Charts must be received by Qsource within 30 calendar days, of the
“date of record request” found on the Chart Request Sheet.
Review Documents Prior to Submitting
Review all documentation for completeness prior to submitting:

Check Prescriptions.

Check Evaluations.

Check IEPs and Annual updates for therapy provided in school.

Check Progress Notes.

Check Signatures – Full name and credentials.

Legible Copies – Ensure information has not been “cut off” during
the copying process and writing is legible.

Highlight in
only.
Annual Update Requirements for Schools
•
An update of progress toward client goals is required annually.
For example:
Evaluation was completed on 1/5/2015.
Then an annual update of progress is due on 1/5/16 and 1/5/17.
•
The therapist can complete these updates independently. They do not have to
be completed as part of the Annual Review Conference held each year at the
school.
•
Annual Review forms completed by the school at the Annual Review
Conference are acceptable if they address progress of the specific type of
therapy under review and cover all dates of service under review.
•
Goal pages within the IEP, IFSP and IPP forms are also acceptable for annual
updates if each goal is updated quarterly, if the date is documented of when
the update occurred and if the dates of service under review are covered.
Arkansas Medicaid Provider Criteria:
www.medicaid.state.ar.us
OT, PT and ST Provider Manual
Section II – Contains Medicaid criteria for services
DMS-640 Completion

Child’s name and Medicaid number.

Diagnosis to support each type of therapy prescribed.

Minutes per week and duration of services prescribed.

Only public schools can document a duration span. For example: school year
(2013-2014) under other information.

Primary Care or Attending Physician must sign and date. Stamped signatures
or dates are not accepted.

Changes made to the prescription that alter the type and quantity of services
prescribed are invalid unless changes are initialed and dated by the physician.

When printing the DMS-640 form from the online Medicaid Provider Manual,
detailed instructions will also print on how to complete the form. Section II –
214.000 E.
DMS-640 Completion – Cont’d





OT, PT and ST services require a referral from the beneficiary’s PCP
unless the beneficiary is exempt from PCP program requirements,
in which case a referral is required from the attending physician.
All referral and prescriptions are required utilizing the DMS-640
form.
Providers of therapy services are responsible for obtaining renewed
PCP referrals every six months even if the prescription for therapy is
for one year.
When seeing a beneficiary for the first time, the initial referral for
evaluation and prescription for treatment must be obtained on
separate DMS-640 forms.
Subsequent referrals and prescriptions for continued therapy may
be made at the same time using the same DMS-640 form.
See Section II – 214.000 A & B
Arkansas Medicaid Provider Manual
Reconsideration of Denials

Reconsideration information must be received in the Qsource office
within 35 calendar days from the date on the initial denial letter.

A copy of the initial denial letter, as well as new or additional
information, must be provided.

Reconsideration information must be MAILED to Qsource.
Attention: Therapy
124 West Capitol Avenue
Suite 900
Little Rock, AR 72201

Only one reconsideration request is allowed per review.
Fair Hearings

To request a fair hearing (appeal), you must do so in writing.

You may not request a hearing and a reconsideration at the
same time.

Please send your request to:
Arkansas Department of Health
Medicaid Provider Appeals Office
4815 West Markham Street
Slot 31
Little Rock, Arkansas 72205
Check the Status of Your Reviews

Go to https://review.qsource-secure.org/provider_home.php.

Choose Selection Date.
 Enter you Provider ID.
 Click: Find My Review.

The review status will reflect what determination has been reached to date on
any specific review and where the chart is in the review process.

The program will provide one of the following responses:
 Chart Not Received
 Review in Progress
 Approved
 Partially Approved
 Denied
 Recon in Process
 Recon Approved
 Recon Denied
 Recon Partial
Doc Upload
Tired of copying all that paper?
Then consider transmitting your records electronically.
If you’re interested, please download and complete the two forms
linked below and mail them to the address noted on the
documentation.
http://qsource.org/arthur/therapy.htm
We will process all completed forms and contact you
with further information.
Sign Up for Quarterly eNewsletter
Want to stay up-to-date on what is happening?
Then sign up for the Qsource Quarterly eNewsletter
for the latest information from Qsource and
Arkansas Medicaid.
http://www.qsource.org/ar/sign-newsletter/
Kay Ewalt, RN
Case Review Manager
kewalt@qsource.org
501-801-6900
Billing Instructions
for Therapists
HP – Fiscal Agent for the
Arkansas Division of Medical Services
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© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Topics for Today
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Therapy Coverage
Exclusions
The Review Process
Billing Claims
Questions
© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Therapy Coverage
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Program Coverage
www.medicaid.state.ar.us
Occupational, physical and speech services are covered only when:
•
•
•
•
•
A PCP (or attending physician if the client is PCP exempt) refers the beneficiary for services.
A PCP (or attending physician if the client is PCP exempt) writes a prescription for services.
Treatment follows a plan of care.
The beneficiary is under 21.
Only speech therapy is covered for ARKids First-B beneficiaries.
Clients over 21 are not eligible for therapy services unless certain conditions are met.
(See section 212.000, G of the Therapy provider manual.)
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Exclusions
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Exclusions
www.medicaid.state.ar.us
Therapy services for individuals over age 21 are only covered when provided through the
following Medicaid programs:
•
•
•
•
•
•
Developmental Day Treatment Clinic Services (DDTCS)
Hospital/Critical Access Hospital (CAH)
Rehabilitative Hospital
Home Health
Hospice
Physician
An individual who has been admitted as an inpatient to a hospital or is residing in a nursing
care facility is not eligible for occupational therapy, physical therapy and speech-language
pathology services under this program. Individuals residing in residential care facilities and
supervised living facilities may be eligible for these therapy services when provided on or off
site from the facility.
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The Review Process
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Retrospective Review
www.medicaid.state.ar.us
Occupational, physical and speech services are reviewed by Qsource of Arkansas for
effective, efficient and economical delivery of services.
Review processes and guidelines are documented in the Therapy provider manual in
sections 214.300 and 214.400.
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Billing Claims
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Augmentative Communication Device
www.medicaid.state.ar.us
Augmentative communication evaluations are covered under Medicaid with prior approval.
Section 231.000 of the Therapy provider manual details the prior authorization process. A
PCP or attending physician referral is required to request the prior authorization from the
Division of Medical Services, Utilization Review Section.
One augmentative communication devices evaluation may be performed every three years
based on medical necessity.
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© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Therapy Benefits
www.medicaid.state.ar.us
Occupational, physical and speech services are limited.
• Medicaid will reimburse up to four (4) occupational, physical and speech therapy evaluation units (1 unit
= 30 minutes) per discipline, per state fiscal year (July 1 through June 30) without authorization.
• Medicaid will reimburse up to four (4) occupational, physical and speech therapy units (1 unit = 15
minutes) daily, per discipline, without authorization.
• All requests for extended therapy services must comply with sections 216.300 through 216.315 of the
Therapy provider manual.
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© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Occupational Therapy Codes
www.medicaid.state.ar.us
Procedure Code
97003
Required
Modifiers
—
Description
Evaluation for Occupational Therapy
(30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30)
97530
—
Individual Occupational Therapy
(15-minute unit; maximum of 4 units per day)
97150
U2
Group Occupational Therapy
(15-minute unit; maximum of 4 units per day, maximum of 4 clients per group)
97530
UB
Individual Occupational Therapy by Occupational Therapy Assistant
(15-minute unit; maximum of 4 units per day)
97150
UB, U1
Group Occupational Therapy by Occupational Therapy Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4 clients per group)
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© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Physical Therapy Codes
www.medicaid.state.ar.us
Procedure Code
97001
Required Modifier
—
Description
Evaluation for Physical Therapy
(30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30)
97110
—
Individual Physical Therapy
(15-minute unit; maximum of 4 units per day)
97150
—
Group Physical Therapy
(15-minute unit; maximum of 4 units per day, maximum of 4 clients per group)
97110
UB
Individual Physical Therapy by Physical Therapy Assistant
(15-minute unit; maximum of 4 units per day)
97150
UB
Group Physical Therapy by Physical Therapy Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4 clients per group)
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Speech Language Pathology
www.medicaid.state.ar.us
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92507
—
Individual Speech Session
92508
—
(15-minute unit; maximum of 4 units per day)
Group Speech Session
92507
UB
92508
UB
92521
UA
92522
UA
92523
UA
92524
UA
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
Individual Speech Therapy by Speech-Language Pathology
Assistant
(15-minute unit; maximum of 4 units per day)
Group Speech Therapy by Speech-Language Pathology
Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
(Evaluation of speech fluency (e.g. stuttering, cluttering) (30minute unit; maximum of 4 units per state fiscal year, July 1
through June 30)
(Evaluation of speech sound production (e.g., articulation,
phonological process, apraxia, dysarthria) (30-minute unit;
maximum of 4 units per state fiscal year, July 1 through June
30)
(Evaluation of speech production (e.g., articulation,
phonological process, apraxia, dysarthria) with evaluation of
language comprehension and expression (e.g., receptive and
expressive language) (30-minute unit; maximum of 4 units per
state fiscal year, July 1 through June 30)
(Behavioral and qualitative analysis of voice and resonance
(30-minute unit; maximum of 4 units per state fiscal year, July
1 through June 30)
© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Speech Language Pathology
www.medicaid.state.ar.us
•
•
When evaluating for Oral Motor/Feeding/Swallowing only – Provider should use code 92522 UA
When evaluating for Oral Motor/Feeding/Swallowing AND language – Provider should use code
92523 UA
For detailed information concerning how to use and bill for these codes, please go to:
http://www.asha.org/Practice/reimbursement/coding/NEW-CPT-Evaluation-Codes-forSLPs/.
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ACD Evaluation
www.medicaid.state.ar.us
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Procedure Code
Description
92607
92608
Augmentative Communication Device Evaluation
© Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Place of Service Codes
www.medicaid.state.ar.us
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Place of Service
Place of Service Code
Doctor’s Office
11
Patient’s Home
12
Day Care Facility
52
Night Care Facility
52
Other Locations
99
Residential
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Billing for School Districts
www.medicaid.state.ar.us
School districts billing for therapy services must use the appropriate Therapy Service
Indicator and 4-digit School District LEA code.
LEA Code
A
Individuals from birth through 2 years (but not 3 years old before September 15 of the current school year) who are receiving therapy
services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services.
B
Individuals ages 0 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an
Individualized Plan (IP) through the Division of Developmental Disabilities Services.
C
Individuals ages 3 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an
Individualized Education Program (IEP) through an education service cooperative.
D
Individuals ages 5 (by September 15) to 21 years who are receiving therapy services under an IEP through a school district.
E
Individuals ages 18 through 20 years who are receiving therapy services through the Division of Developmental Disabilities Services.
F
Individuals ages 18 through 20 years who are receiving therapy services from individual or group providers not included in any of the
previous categories (A-E).
Individuals ages birth through 17 years who are receiving therapy/pathology services from individual or group providers not included in any
of the previous categories (A-F).
G
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Description
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Questions?
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Thank You
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